[Medical and surgical management of noniatrogenic traumatic tracheobronchial injuries]. / Manejo médico-quirúrgico de las lesiones traqueobronquiales traumáticas no iatrogénicas.

OBJECTIVE: To describe the medical and surgical management of noniatrogenic traumatic tracheobronchial injuries. PATIENTS AND METHOD: From January 1993 to July 2004, 15 cases of traumatic tracheobronchial injury were treated in our department. The diagnosis was established by bronchoscopy and a computed tomography chest scan was performed on all patients. Surgical treatment was selected for patients with unstable vital signs, an open tracheal wound, associated esophageal lesions, progression of subcutaneous or mediastinal emphysema, mediastinitis or suspicious mediastinal secretions on imaging tests, or difficulties with mechanical ventilation due to the traumatic tracheobronchial injury. RESULTS: The mean (SD) age of the patients was 35.5 (18.9) years and 12 (80%) were male. Of the 15 cases, 13 (86.7%) had penetrating trauma and 2 (13.3%) blunt trauma. The most common location of the injury was in the bronchi (9 cases; 60%), followed by the cervical trachea (4 cases; 26.6%), followed by both the thoracic trachea and bronchi (2 cases; 13.4%). The most common initial symptom was subcutaneous emphysema, which presented in 11 (73.3%) patients. Chest (12 cases; 86.7%) and orthopedic injuries (9 cases; 60%) were the most common associated injuries. Surgery was the treatment of choice in 11 (73.3%) cases and conservative medical treatment in 4 (26.7%). An irreversible brain injury caused the death of 1 patient receiving conservative treatment. CONCLUSIONS: Tracheobronchial injuries may be treated conservatively if they meet strict selection criteria. Size and location should not be used as selection criteria for surgical treatment.

Manejo médico-quirúrgico de las lesiones traqueobronquiales traumáticas no iatrogénicas / Medical and surgical management of noniatrogenic traumatic tracheobronchial injuries

Objetivo: Describir el manejo médico-quirúrgico de las lesiones traqueobronquiales traumáticas no iatrogénicas. Pacientes y método: De enero de 1993 a julio de 2004 se registraron en nuestro servicio 15 casos de lesiones traqueobronquiales traumáticas. En todos los pacientes el diagnóstico se estableció por broncoscopia y a todos se le realizó una tomografía computarizada de tórax. Se eligió tratamiento quirúrgico cuando había inestabilidad vital del paciente, herida traqueal abierta, lesiones esofágicas asociadas, progresión de enfisema subcutáneo o mediastínico, mediastinitis o colecciones mediastínicas sospechosas en pruebas de imagen o dificultades en la ventilación mecánica por la lesión traqueobronquial traumática. Resultados: La edad media (± desviación estándar) de los pacientes fue de 35,5 ± 18,9 años y 12 (80%) eran varones. Se registraron 13 traumatismos cerrados (86,7%) y 2 abiertos (13,3%). La localización más frecuente de la lesión fue bronquial (9 casos; 60%), seguida de tráquea cervical (4 casos; 26,6%) y tráquea toracicobronquial (2 casos; 13,4%). El síntoma inicial más frecuente fue el enfisema subcutáneo, que presentaron 11 pacientes (73,3%). Las lesiones asociadas más frecuentes fueron torácicas, con 12 casos (86,7%), seguidas de ortopédicas, con 9 (60%). El tratamiento de elección fue quirúrgico en 11 casos (73,3%) y médico conservador en 4 (26,7%). Falleció una paciente tratada de forma conservadora por lesión cerebral irreversible. Conclusiones: Las lesiones traqueobronquiales pueden tratarse de forma conservadora si cumplen criterios estrictos de selección. El tamaño o la localización no debe ser un criterio para la elección del tratamiento quirúrgico

Objective: To describe the medical and surgical management of noniatrogenic traumatic tracheobronchial injuries. Patients and method: From January 1993 to July 2004, 15 cases of traumatic tracheobronchial injury were treated in our department. The diagnosis was established by bronchoscopy and a computed tomography chest scan was performed on all patients. Surgical treatment was selected for patients with unstable vital signs, an open tracheal wound, associated esophageal lesions, progression of subcutaneous or mediastinal emphysema, mediastinitis or suspicious mediastinal secretions on imaging tests, or difficulties with mechanical ventilation due to the traumatic tracheobronchial injury. Results: The mean (SD) age of the patients was 35.5 (18.9) years and 12 (80%) were male. Of the 15 cases, 13 (86.7%) had penetrating trauma and 2 (13.3%) blunt trauma. The most common location of the injury was in the bronchi (9 cases; 60%), followed by the cervical trachea (4 cases; 26.6%), followed by both the thoracic trachea and bronchi (2 cases; 13.4%). The most common initial symptom was subcutaneous emphysema, which presented in 11 (73.3%) patients. Chest (12 cases; 86.7%) and orthopedic injuries (9 cases; 60%) were the most common associated injuries. Surgery was the treatment of choice in 11 (73.3%) cases and conservative medical treatment in 4 (26.7%). An irreversible brain injury caused the death of 1 patient receiving conservative treatment. Conclusions: Tracheobronchial injuries may be treated conservatively if they meet strict selection criteria. Size and location should not be used as selection criteria for surgical treatment

[Importance of routine mediastinal staging in women with non-small cell lung cancer]. / Importancia de la estadificación mediastínica, sistemática en mujeres con carcinoma broncogénico, no microcítico.

OBJECTIVE: To study the specific importance of mediastinal staging in women with nonsmall cell lung cancer. PATIENTS AND METHODS: Between July 1981 and September 2003 we surgically staged 2172 patients with nonsmall cell lung cancer who met the inclusion criteria for resectability and operability. A subgroup of 108 women was studied. Cervical mediastinoscopy was performed in all cases, with the addition of anterior mediastinotomy in cases with left upper lobe involvement. All patients underwent a preoperative computed tomography chest scan. RESULTS: Cervical mediastinoscopy was performed on all 108 patients, 26 of whom also underwent anterior mediastinotomy. Positive findings were recorded in 44 (40.7%) of the 108 cases: 39 of the 108 mediastinoscopies (36.1%), 9 of the 26 mediastinotomies (34.6%), and in 5 cases (19.2%) both mediastinoscopy and mediastinotomy. Nodal involvement was found in 13% of cases in clinical stage IA and 30.8% of cases in clinical stage IB. The percentage of positive findings was significantly higher for cases with adenocarcinoma or large cell carcinoma (P<.05). We performed 67 thoracotomies: 46 patients underwent lobectomy (42.6% of the 108), 7 bilobectomy (6.5%), 9 pneumonectomy (8.3%), and 5 exploratory thoracotomy (4.6%). The agreement between clinical staging after mediastinoscopy and pathological staging after thoracotomy was 47% (stage IA) and 57% (stage IB). CONCLUSIONS: Routine mediastinoscopy is indicated for all women with nonsmall cell lung cancer, regardless of clinical stage.

Importancia de la estadificación mediastínica, sistemática en mujeres con carcinoma broncogénico, no microcítico / Importance of routine mediastinal staging in women with nonsmall cell lung cancer

OBJETIVO: Investigar la importancia específica de la estadificación mediastínica de mujeres con carcinoma broncogénico, no microcítico. PACIENTES Y MÉTODOS: Entre julio de 1981 y septiembre de 2003 estadificamos quirúrgicamente a 2.172 pacientes con carcinoma broncogénico no microcítico que cumplían criterios de resecabilidad y operabilidad. Se realizó mediastinoscopia cervical de forma habitual, y mediastinotomía anterior en caso de afectación del lóbulo superior izquierdo. Todos los pacientes tenían una tomografía axial computarizada de tórax preoperatoria. Se estudió al subgrupo de 108 mujeres. RESULTADOS: Realizamos mediastinoscopia cervical en 108 casos y mediastinotomía anterior en 26. Fueron positivas 44 (40,7%) —39 (36,1%) mediastinoscopias, 9 (34,6%) mediastinotomías y en 5 (19,2%) casos ambas—. Se objetivó afectación ganglionar en un 13% de los casos en estadio IA y en un 30,8% en estadio IB. El porcentaje de positividad fue significativamente mayor en caso de adenocarcinoma o carcinoma de células grandes (p < 0,05). Realizamos 67 toracotomías: 46 (42,6%) lobectomías, 7 (6,5%) bilobectomías, 9 (8,3%) neumonectomías y 5 (4,6%) toracotomías exploradoras. La concordancia entre estadificación clínica posmediastinoscopia y patológica postoracotomía fue del 47% (IA) y del 57% (IB). CONCLUSIONES: La mediastinoscopia sistemática está indicada en todas las mujeres con carcinoma broncogénico no microcítico independientemente del estadio clínico

OBJECTIVE: To study the specific importance of mediastinal staging in women with nonsmall cell lung cancer. PATIENTS AND METHODS: Between July 1981 and September 2003 we surgically staged 2172 patients with nonsmall cell lung cancer who met the inclusion criteria for resectability and operability. A subgroup of 108 women was studied. Cervical mediastinoscopy was performed in all cases, with the addition of anterior mediastinotomy in cases with left upper lobe involvement. All patients underwent a preoperative computed tomography chest scan. RESULTS: Cervical mediastinoscopy was performed on all 108 patients, 26 of whom also underwent anterior mediastinotomy. Positive findings were recorded in 44 (40.7%) of the 108 cases: 39 of the 108 mediastinoscopies (36.1%), 9 of the 26 mediastinotomies (34.6%), and in 5 cases (19.2%) both mediastinoscopy and mediastinotomy. Nodal involvement was found in 13% of cases in clinical stage IA and 30.8% of cases in clinical stage IB. The percentage of positive findings was significantly higher for cases with adenocarcinoma or large cell carcinoma (P<.05). We performed 67 thoracotomies: 46 patients underwent lobectomy (42.6% of the 108), 7 bilobectomy (6.5%), 9 pneumonectomy (8.3%), and 5 exploratory thoracotomy (4.6%). The agreement between clinical staging after mediastinoscopy and pathological staging after thoracotomy was 47% (stage IA) and 57% (stage IB). CONCLUSIONS: Routine mediastinoscopy is indicated for all women with nonsmall cell lung cancer, regardless of clinical stage

[Technical complications in the surgical inspection of the mediastinum in the staging of cancer of the lung]. / Complicaciones técnicas de la exploración quirúrgica del mediastino en la estadificación del cáncer de pulmón.

Between January 1974 and December 1996 we performed exploratory surgery (mediastinoscopies/mediastinotomies) on 1,618 patients diagnosed of bronchogenic carcinoma who were considered functionally operable and whose cancer was believed to be resectable. Findings were positive in 26%. Thirty-four (2.1%) complications were encountered, with a significantly higher incidence of complication among those for whom the results of exploratory surgery were positive (p = 0.004) as follows: only 13 cases (0.8%) of significant bleeding; 12 cases (0.74%) of recurrent left nerve palsy (0.74%), 4 (0.25%) subcutaneous wound infections; 3 cases (0.18%) of pneumothorax; 1 (0.06%) perforated esophagus; and 1 case (0.06%) of chylomediastinum. The rate of morbidity associated with exploratory surgery was within the range reported in the literature. No deaths occurred. Mediastinoscopy, in our experience, is the most effective way of staging mediastinal ganglia. Provided the procedure is performed carefully by experienced surgeons, the risk of complication is minimal.

[Pulmonary lymphangioleiomyomatosis (LAM). Diagnostic usefulness of immunohistochemical markers]. / Linfangioleiomiomatosis pulmonar (LAM). Utilidad diagnóstica de los marcadores inmunohistoquímicos.

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown cause affecting the lungs of female patients. Although clinical and radiological findings may suggest LAM, a firm diagnosis is usually made after lung biopsy. Cases of LAM (histochemical diagnosis) or "suggestive of LAM" at the "12 of October" Hospital are reviewed. We applied a battery of immunohistochemical tests not used to date--involving estrogen, progesterone, desmin and HMB45 receptors--that allowed us to classify specimens as having either LAM lesions or lesions with non-LAM muscle proliferation. Smooth muscle proliferation in LAM is a distinct phenotype, such that diagnosis is facilitated by analyzing for immunohistochemical markers such as HMB45. This marker can be detected on formalin-fixed paraffin-embedded sheets in specimens obtained by either open lung or transbronchial biopsy.